MEDICARE: KIM GAY SPARGO LADC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	398	NE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	85743	OTHER	NE	BLUECROSS BLUESHIELD

General Provider Information

NPI Number	:	1740481738
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIM GAY SPARGO LADC

Provider Business Mailing Address
First Line	:	425 N OAK ST
Second Line	:
City	:	NORTH PLATTE
State	:	NE
Zip	:	69101-3764
Country	:	US
Telephone Number	:	308-532-8300
Fax Number	:

Provider Business Practice Location Address
First Line	:	425 N OAK ST
Second Line	:
City	:	NORTH PLATTE
State	:	NE
Zip	:	69101-3764
Country	:	US
Telephone Number	:	308-532-8300
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/29/2007
Last Update Date	:	07/08/2007

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